Interview conducted by April Cashin-Garbutt, BA Hons (Cantab)
Please could you define obesity in children?
Childhood obesity is harder to define than adult obesity. This is because any definition of obesity relies on measurements of both height and weight, and the calculation of body mass index (BMI) based on these measurements.
Until later stages of puberty, children are still growing, implying their height is changing continuously, but not necessarily at the same time or rate as the height of their peers. Therefore, in children, definitions of obesity should include height, weight, age and gender.
There are various definitions for obesity in children. I like the following definition, for children aged 2-19 years, endorsed by the Centre for Disease Control (CDC) in Atlanta, as the CDC website offers a link to calculating the age-matched and gender-matched standard deviation score of the calculated BMI.
Overweight is defined as a BMI at or above the 85th percentile and lower than the 95th percentile for children of the same age and sex.
Obesity is defined as a BMI at or above the 95th percentile for children of the same age and sex.
This definition is based on a consensus group recommendation (reference: Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Supplement December 2007:S164—S192.)
How did your interest into childhood obesity originate?
I am a paediatric endocrinologist, and children with obesity are commonly referred to paediatric endocrinologists for management of the diabetes and metabolic abnormalities commonly associated with obesity.
I have been interested in childhood obesity since I began studying and managing its effects in children. Recently, I have seen increasing numbers of children with obesity and its complications. I have been particularly interested in it because it is potentially preventable; despite that, more and more children are presenting with, not just obesity, but complicated obesity.
I am very fortunate to work on several research projects with my research group, some of whom worked on this study. This group comprises paediatricians, general practioners, exercise experts and nutrition experts (both laboratory based and clinical) from Ireland and Canada who come together at the Centre for Interventions in Infection, Inflammation and Immunity (4i Research Centre) at the University of Limerick, Ireland (www.4i.ie). The 4i Research Centre was recently established under the directorship of Professor Colum Dunne as the research vehicle of the Graduate Entry Medical School in the University of Limerick. At 4i, we have several other studies into childhood obesity ongoing.
This includes one funded by the National Children’s Research Centre in Dublin, about which we are very excited. Its investigator, Dr Alan Macken, also a paediatrician, is recruiting young children whose fathers have had major cardiac events at young ages, and evaluating the children for evidence of abnormal cardiometabolic health, compared with control children of healthy parents.
Dr Paul Scully is conducting, in fact, completing, a detailed study of food and exercise cues to which children are exposed when they watch children’s television broadcasting in Ireland and the United Kingdom. This encompasses the types of advertisements children see during broadcast programs.
PhD candidate Kieran Dowd, supervised by my colleague Professor Alan Donnelly, is conducting a novel longitudinal follow-up study of exercise and sedentariness in adolescent girls, along with a detailed health assessment in these girls.
Recently, some of us established a dedicated children’s obesity clinic at the University Hospital, Limerick. This is a pilot clinic at the moment, but there is a huge clinical need for it and I hope that it will be funded so we can continue to see children with obesity there. It is one of the first dedicated children’s weight management clinics in Ireland. I am fortunate to have both Irish and Canadian colleagues for many of these research studies and for the children’s obesity clinic. The international connection gives us all the chance to compare ideas and adopt strategies from each other.
What did your recent research involve?
My research team and I interviewed children admitted to our general paediatrics ward & their parents about 2 things:
The types and amounts of food they were eating in hospital, and whether this differed to their eating habits at home.
Whether the parents knew the weight of their child and whether they thought their child’s weight was normal, or not.
What did your research find?
We found that a significant number of children had very unhealthy diets while they were patients in the hospital; many children ate fried food and very few ate fruit and vegetables while there. It is true that there are times when children perhaps should be indulged, and that a stay in hospital is perhaps one of those times. But, disappointingly, many of the parents reported that their children’s diets at home were largely similar to their diets in the hospital. Additionally, many parents brought take away fast food into the hospital for their children to eat.
Also, we found that many of the children (just less than one third) were overweight or obese and, disappointingly, many (two-thirds) of the parents of these children thought that their children were normal weights for their age.
Did your research show a difference between the obesity rates in boys and girls?
It showed more overweight and obesity in boys than in girls. Remember, of course, that it was only a small study.
How did the obesity rates of children differ with age?
The study was really too small to comment reliably on this. But it appeared that overweight and obesity was a much less prevalent problem in children under 5 years old, and really became more prevalent and more problematic after the age of 5 years.
What impact do you think your research will have?
If this research starts a discussion about the quality of food children eat in hospital, I will be happy. It has already generated some discussion on radio programs and in newspapers. But I hope that this discussion will continue, because the problem has not gone away so neither should our concerns.
The results of this study are only a proxy for the food children in general are eating, however. The food a child eats in hospital certainly depends on the food that the hospital serves, and efforts should be made to improve this. But parents also need to take responsibility for the food their children eat, at home and outside the home, including in the hospital.
I hope that this study will be a cause for concern and be thought-provoking for parents, health care providers and policy makers.
What do you think needs to happen to reduce childhood obesity rates?
Importantly, something has to happen. Recent years have shown us that, despite some attempts at intervention, childhood obesity is increasing. What is now needed, in my opinion, is a concerted, multi-faceted approach.
Any therapy to support the child needs to be family-focused; the child does not buy the groceries or cook the meals; therefore the whole family needs to want to change its habits. Schools, crèches, hospitals, clubs and other places where children congregate and, perhaps, eat, need to be supportive of change.
Policy-makers must advocate for the health of children. This might imply that children are not exposed to food or beverage advertisements during children’s broadcasting hours and their families are incentivized to make healthy food choices. Notwithstanding, children need to watch less television and have less other screen-time (e.g. computers and videogames) and need instead to get outside to play. To facilitate that, the streets and playgrounds must be local, well-lit and safe for children.
Health care professionals need to adapt themselves so that they don’t just treat kids who already have weight problems. Instead, they need to start taking every available opportunity to discuss healthy food and lifestyle choices with parents and, indeed, with children. There are guidelines from the Department of Health and Children on healthy food intake for children. Unfortunately, in our study, parents did not know the guidelines or the contents of these guidelines.
What seems to be missing is the communication, education and empowerment of the people who provide food and lead by example to children. This is probably the kernel of the problem. How to change behaviour patterns, when those whose behaviour needs to be changed are unaware of the need to change, of the implications of not changing and of how or what to change. Children in schools need to learn the basics of healthy food and lifestyle choices, but so do their parents. What is unclear is how or where to address the communication, education and empowerment of parents.
Some advocate taxing “unhealthy” foods, as a disincentive to the purchase (and hence, theoretical, provision to children) of these “unhealthy” foods. Unfortunately, unless we show parents the alternative foods, where to buy them (cheaply) and how to prepare them (simply), then taxes are not likely to work. Alternatives have to be highlighted and made accessible.
The lifestyle and exercise part of the discussion is interesting. At an individual level, it is important to encourage each individual child to participate in sports for fun; the consequent health benefits of exercise are not usually the child’s motivating factor!
At a population level, however, it is likely that there is more to be gained from discouraging sedentary lifestyles in kids, than from encouraging activity and sports in kids. This might mean encouraging kids to walk to school, to take the stairs not the lift, or to get them to do some housework or work in the garden. Depending on the age of the child, teaching them to be less inactive, by participating in activities of normal everyday life, might offer them a sustainable active lifestyle for the future. Exercise does not offer this to all children.
While this concerted, multi-faceted approach to childhood obesity is being undertaken, it is important that children with weight issues should not be ostracized or isolated. Studies have suggested that obese kids have poor quality of life scores, as poor as those of kids undergoing cancer treatment, in fact. Isolating these kids, emotionally and physically, will only exacerbate their problems.
Are there any plans in place to achieve this?
I think that parents and those who provide care for children are thinking about childhood weight issues more than ever before. This is an important step. Health care professionals also seem to be more aware of problems, at even younger ages and before the weight issues lead to metabolic complications. Society is clearly increasingly aware of the problem. Obesity task forces have been convened to try to tackle various aspects of the problem.
But childhood obesity is a clinical problem with its root in society and in the habits of generations. It will not be easily tackled.
Do you have any plans for further research into this area?
Absolutely. My research team and I have many plans for further research, in several of the areas alluded to above.
Would you like to make any further comments?
I truly hope that all parties can come together to make a difference in tackling childhood obesity. This condition has an overwhelming impact on the health of the child: the obese child will become the extremely obese adult. It has enormous financial and economic implications for our health service and the health of our nation in the future. The problem of paediatric obesity is not coming: it is here already. And we will only make a difference by working together.
One of the enormous differences between obesity in children and in adults, is that the aim of treating children is often to help the child to achieve weight maintenance, not weight loss. Weight maintenance is often an apparently easier target for the child and, as the child grows taller, their BMI falls. This knowledge can be very empowering for children. In parallel with this, it is important to reinforce to the child that their physical health is more important than their actual weight, and so the child can try to become fitter and healthier, even at their current weight.
Where can readers find more information?
About Prof Clodagh O’Gorman
Prof Clodagh O’Gorman was appointed to the role of Foundation Chair, Professor of Paediatrics, Graduate Entry Medical School, University of Limerick and Consultant Paediatrician with special interest in Paediatric Diabetes and Endocrinology in 2009. She is also a Founding Principal Investigator of the 4i Research Centre at University of Limerick.
Prior to this, she worked and trained in general paediatrics and paediatric diabetes and endocrinology in Ireland and at The Hospital for Sick Children, Toronto, Canada.
She is a Medical Doctorate and Medicine graduate from the National University of Ireland, Galway and a Masters of Science graduate from the University of Oxford.
She is a Member of the Royal College of Physicians of Ireland, where she is an examiner for the RCPI examinations and she is a faculty board member of the Faculty of Paediatrics.
She has authored and published significant papers in the areas of general paediatrics, and in particular paediatric diabetes, paediatric obesity and paediatric endocrinology. Her current research interests focus on aspects of paediatric obesity, including risks of diabetes and metabolic disease in children with various disorders.
Amongst other funded studies, she and her research colleagues are currently funded to study these risks in a group of healthy children whose parents have had heart disease. She is frequently invited to speak to various professional groups.
Since her arrival to Limerick in 2009, she has established a new paediatric obesity service, a new paediatric endocrinology service, and she is in the process of establishing a service for the commencement of insulin pump therapy for children with type 1 diabetes mellitus.
She recently sat on the Dolphin Review Group, a group convened by the Minister for Health to report on the future development of Ireland’s new National Paediatric Hospital.